Association of protocolized slow stapled pancreatic transection with clinically relevant postoperative pancreatic fistula after distal pancreatectomy

Abstract Purpose: Clinically relevant postoperative pancreatic fistula (POPF) remains common after distal pancreatectomy (DP). We assessed whether a standardized very slow stapling technique (VSST) was associated with lower POPF after stapled DP. Methods: Consecutive patients undergoing DP/DP-CAR/SPDP (2014–2026) were reviewed. VSST (introduced January 2024) comprised no precompression, very slow firing (~ 1 cm/5 min), and avoidance of concomitant manipulation. Analyses were restricted to stapled cases; multivariable logistic regression assessed risk factors for grade B/C POPF. Results: Of 211 patients, 184 had stapled transection (VSST 45; conventional 139). Grade B/C POPF occurred in 2/45 with VSST versus 31/139 (22.3%) with conventional stapling (P < 0.01). VSST remained associated with lower POPF (adjusted OR 0.16, 95% CI 0.025–0.57; P < 0.01). Among patients with a thick pancreas (≥ 13 mm; n = 66), VSST was independently associated with lower POPF (adjusted OR 0.14, 95% CI 0.01–0.83; P = 0.031). Overall Clavien–Dindo grade ≥ III complications did not differ between groups (6/45 vs 27/139; P = 0.35), whereas POPF-related grade ≥ III complications were significantly less frequent with VSST (2/45 vs 23/139; P = 0.039). Conclusion: VSST was associated with lower clinically relevant POPF and fewer POPF-related major complications after stapled distal pancreatectomy; prospective multicenter validation with prespecified stratification by pancreatic thickness is warranted.